Psychotherapy training may often be seen as separate from the educational work that goes on daily in our clinics and wards. It has been my long-standing aim to develop training in psychiatry to include initiatives that can incorporate new methods of skills development. How to develop psychodynamic skills that can be used routinely by mental health professionals in their daily practice is a problem that I have been trying to solve for many years as an educator. This brief article describes some educational developments that arose from one of my projects in this area.
Interpersonal dynamics training programme
The idea for the programme originated from a presentation on operationalised psychodynamic diagnostics (OPD) by a team of psychiatrists from Germany, who worked in a clinic for psychosomatic medicine and psychotherapy (Reiss Reference Reiss and Kirtchuk2009). Although they were not forensic psychiatrists, the presentation took place at Broadmoor Hospital, a high-security mental health facility in Berkshire, UK. It is important that we do not stick to professional silos and use innovations we find in other subspecialties that can be adapted and implemented in our own practice.
My late colleague Dr Gabriel Kirtchuk and I, together with other members of the forensic psychotherapy department at West London NHS Trust, developed part of the OPD approach, which analysed, using a structured framework, the interpersonal dynamics between patients and staff (Reiss Reference Reiss and Kirtchuk2009; Kirtchuk Reference Kirtchuk, Gordon and McAlister2013). The method, initially employed on a medium secure in-patient unit, lends itself to involving resident doctors at all levels of training, as they have the appropriate knowledge and skills to contribute effectively from an early stage.
The procedure
The basic procedure (Kirtchuk Reference Kirtchuk, Gordon and McAlister2013) is initially to present previously gathered background information about the patient, highlighting the interpersonal dynamics in childhood, later in life (including any index offence) and the present time. The team is then tasked to conceptualise four perspectives of core relationship patterns that the patient manifests by clarifying:
-
(a) how the patient characteristically perceives the other;
-
(b) how the patient responsively experiences themselves;
-
(c) how others (including staff members) usually perceive the patient;
-
(d) how others/staff experience themselves in their interactions with the patient.
These perspectives, taken together, outline the transference–countertransference configurations enacted between patient and staff, as experienced in the care setting. The contents of the perspectives are elicited via a multidisciplinary staff team meeting with an appropriately skilled facilitator. Once the core dynamics are identified, in the form of a circular formulation, it becomes possible to link past experiences in the patient’s life with unwitting repetitions of those past patterns between patient and staff, including those that may promote splitting of the team and/or lead to increased risk.
Implementation
The interpersonal dynamic approach was used as part of core psychiatry training, fitting in with the specified curriculum. We involved ward doctors for the individual patients whose cases were going to be analysed using this method. They assisted in organising the multidisciplinary team meeting, presented a summary of the case with the appropriate information, and provided aspects of current interpersonal information. Finally, they developed a simple formulation, although more advanced formulation skills were generally not included in their educational objectives. The residents at this stage could thereby gain skills in gathering information, presenting the relevant focused details and making sense of the basic dynamics.
At the next level of training, post-MRCPsych, residents could develop their skills further, including more complex levels of psychodynamic assessment and formulation, such as explaining splits within the team, as well as being able to outline an intervention plan, incorporating measures to reduce risk. Some could even, with appropriate supervision, lead the group process. Opportunities were subsequently available for interested and enthusiastic trainees to assist in the writing of chapters on the process for various books (Dale Reference Dale, Kirtchuk, Reiss, Rubitel and Reiss2011; Darnley Reference Darnley, Reiss, Kirtchuk, Aiyegbusi and Kelly2012; Kirtchuk Reference Kirtchuk, Reiss, Alla, Puri and Treasaden2017). These articles were usually inspired by cases that had been worked up into presentations, so the trainees accompanied the original authors to professional conferences, including internationally.
An additional aspect that followed, inspired by the previous work, was a training programme for higher residents from a variety of specialties, which gave them the interpersonal and organisational skills that they needed to apply the consultation approach in general medical settings (Li Reference Li, Hillen and Reiss2019). There was an even more advanced opportunity for a senior resident, who was specifically funded for this purpose from an educational grant, to organise the recruitment of interested trainees. This post-holder also helped develop the advanced level liaison training programme, which was provided with the assistance of consultant staff.
The programme therefore provided high-quality educational outputs in a wide variety of areas, in both skills training as well as dissemination through educational presentations and articles.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
eLetters
No eLetters have been published for this article.